Therapeutics and Clinical Risk Management
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Epidemiology and risk factors for invasive
candidiasis
Nur Yapar
Department of Infectious Diseases
and Clinical Microbiology, Faculty
of Medicine, Dokuz Eylül University,
İzmir, Turkey
Correspondence: Nur Yapar
Department of Infectious Diseases and
Clinical Microbiology, Faculty of Medicine,
Dokuz Eylül University, Mithatpasa Street,
35340 Inciralti İzmir, Turkey
Email nur.yapar@deu.edu.tr;
nuryapar@gmail.com
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http://dx.doi.org/10.2147/TCRM.S40160
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Abstract: The number of immunosuppressive patients has increased significantly in recent years.
These patients are at risk for opportunistic infections, especially fungal infections. Candidiasis
is one of the most frequent fungal infections determined in these immunosuppressive patients
and its epidemiology has changed over the last two decades. Recently, new antifungal agents and
new therapy strategies such as antifungal prophylaxis, secondary prophylaxis, and preemptive
therapy have come into use. These changes resulted in the alteration of Candida species causing
invasive infections. The incidence of Candida albicans was decreased in many countries, espe-
cially among patients with immunosuppressive disorders, while the incidence of species other
than C. albicans was increased. In this review, incidence, risk factors, and species distribution
of invasive candidiasis are discussed.
Keywords: candidemia, invasive candidiasis, incidence, species distribution, risk factors
Introduction
As a result of presently used treatments for malignant diseases and HIV/AIDS, and the
advances in intensive care unit (ICU) interventions and organ transplantation, many
diseases no longer pose a threat to humans and life expectancy is prolonged. However,
this has also caused an increase in various opportunistic infections, and most of all,
fungal infections. With an increase in the number of individuals sensitive to invasive
fungal infections, both molds and yeasts have begun to be reported more frequently
as pathogens. When all at-risk groups are considered as a whole, it is seen that the
leading pathogen is Candida species.1 In the USA, it is among the top five pathogens
causing nosocomial blood stream infections (BSIs) and Candida species cause 8% to
10% of nosocomial BSIs.1–4 Population-based surveillance studies report the yearly
incidence of Candida infections as eight per 100,000 population.1
The scope of candidiasis covers a wide range of diseases from more superficial
and milder clinical manifestations such as esophageal or oropharyngeal candidiasis to
serious infections including BSIs and disseminated candidiasis, whereas the descrip-
tion of invasive candidiasis (IC) encompasses severe diseases such as candidemia,
endocarditis, disseminated infections, central nervous system infections, endophthal-
mitis, and osteomyelitis.2 Underlying malignancies, immunosuppressive diseases,
hematopoietic stem cell or solid organ transplantation, the use of wide-spectrum anti-
biotics or corticosteroids, invasive interventions, aggressive chemotherapy, parenteral
alimentation, and internal prosthetic devices increase the risk of candidiasis.2 In spite
of the advances achieved in the diagnosis and treatment of candidiasis, the infection
still causes high mortality rates.2,5
Therapeutics and Clinical Risk Management 2014:10 95–105 95
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Yapar
Currently, there are more than 150 known species of
Candida. However only 15 of these species are isolated
from patients as infectious agents. These are Candida
albicans, Candida glabrata, Candida tropicalis, Candida
parapsilosis, Candida krusei, Candida guilliermondii,
Candida lusitaniae, Candida dubliniensis, Candida pellicu-
losa, Candida kefyr, Candida lipolytica, Candida famata,
Candida inconspicua, Candida rugosa, and Candida
­norvegensis. Although the isolation frequencies may vary, in
the last 20–30 years, it has been determined that in 95% of
infections, the pathogens involved are C. albicans, C. glabrata,
C. parapsilosis, C. tropicalis, and C. krusei.1,2,6,7 Among these
species, C. albicans is still the most common pathogen in spite
of its dwindling share. In humans, it generally colonizes some
regions including skin, oropharynx, lower respiratory tract,
gastrointestinal tract, and genitourinary system.1,2 The isola-
tion rates of species other than C. albicans vary according to
the features (age, underlying diseases, hospitalization ward,
etc) of patient population. To illustrate, C. parapsilosis causes
30% of the candidemia cases among newborns whereas the
rate is 10%–15% among adults. C. glabrata is a more com-
mon infectious agent among older and neoplastic patients.
C. tropicalis, on the other hand, is more commonly seen
among leukemia patients and neutropenic patients. Since C.
parapsilosis colonizes the skin, it is a common pathogen in
catheter-related infections and may cause outbreaks. C. krusei,
on the other hand, is more common among hematopoietic
stem cell recipients or neutropenic leukemia patients receiving
fluconazole prophylaxis.1,2
The present article reviews the incidence of IC, the
most common infectious pathogens and the risk factors for
candidiasis. For this purpose, a literature search was performed
in last 15 years via PubMed using keywords candidemia,
invasive candidiasis, epidemiology, surveillance, incidence,
species distribution, and risk factors. National or multinational
surveillance studies and multicenter studies written in English
were included. The studies were evaluated according to the
following regions of the world: North America, Latin America,
Europe, Asia-Pacific, Middle East, and Africa. In case of lack
of surveillance studies or multicenter researches, large series
conducted in a single center were included.
The incidence of IC
A brief review of the epidemiologic studies related to inva-
sive fungal infections shows that articles where national
surveillance data are examined and multicenter studies
mostly originate from North America. Although there are
some multicenter studies in the literature that originate from
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European countries and some other parts of the world, most
of these articles generally include data from single centers.
The number of national surveillance studies and multinational
researches has shown an increase in the last 10 years. Along
with studies conducted in single centers, epidemiologic stud-
ies analyzing certain patient groups (ICU patients, patients
with hematologic malignancies, solid organ transplant recipi-
ents, newborns, geriatric patients, etc) also result in overly
diverse epidemiological data.
According to the data provided by the Centers for
Diseases Control and Prevention (CDC) and the National
Healthcare Safety Network, Candida species are ranked fifth
among hospital-acquired pathogens and fourth among BSI
pathogens.1–4 IC seems to be more of a nosocomial infection
when its hospital incidence and health-care-associated risk
factors such as the involvement of invasive interventions and
long-term antibiotic use are considered. However, the rate
of community-acquired cases is not to be underestimated.
According to the results of the SENTRY Antimicrobial
Surveillance Program, 1,354 infection episodes related to
Candida species were detected between 2008 and 2009 and
36.5% of these were community-acquired.8 Community-
acquired candidemia was found to be significantly higher in
North America (63.5%) than in Europe (22.4%).8
Data from population-based studies
It was reported that the incidence rates of IC have increased
both in Europe and the USA from the 1970s to the early 1990s
and were stabilized after the 1990s.1,2,9 The first reports about
the population-based incidence of candidiasis are the CDC
data collected between 1992 and 1993.9 According to those
data, the yearly incidence of IC was reported as 7.28/100,000
population. In a study by Zilberberg et al, despite regional
differences, candidemia incidence was found to be 3.65 per
100,000 population in 2000 and 5.56 per 100,000 population
in 2005 and the increase throughout the years was found to
be significant.10 The authors documented a 50% increase
in hospitalization with candidemia from January 2000 to
December 2005.10 The regional differences in incidence are
more prominent in studies planned by the CDC, which were
conducted in Atlanta, GA, USA and Baltimore, MD, USA.
During 1992–1993, candidemia incidence was found as
8.7/100,000 in Atlanta, whereas an incidence of 24/100,000
was determined in Baltimore between 1998 and 2000.11,12
According to a surveillance study conducted in the same
regions between 2008 and 2011, the incidence was calculated
as 13.3 and 26.2 per 100,000 population for Atlanta and
Baltimore, respectively.11,12 The yearly IC incidence reported
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on the USA National Center for Health Statistics is eight per
100,000 population.13
Except for Denmark, IC incidence in Europe is lower
than in the USA. According to the national surveillance
studies conducted between 2004–2009 and 2010–2011,
the mean incidences in 2004–2009 and 2010–2011 periods
were found as 8.6 (minimum: 7.9, maximum: 9.8) and 9.4
(minimum: 8.82, maximum: 10.05) cases per 100,000 inhab-
itants, respectively.14,15 Even lower rates were determined in
Finland and Sweden. Poikonen et al reported a yearly mean
incidence of 2.86 cases per 100,000 population in Finland
between 2004 and 2007.16 As for Sweden, a yearly incidence
of 4.2 cases/100,000 population was determined between
2005 and 2006.17
A population-based surveillance study conducted in
Australia between 2001 and 2004 reported a yearly can-
didemia incidence of 1.81 cases per 100,000 population.18
Chen et  al reported that the incidence rate was highest
among infants and adults aged 65 years and older (24.8 and
13.7/100,000 population, respectively).18 Studies on children
also support these findings. IC incidence is much higher
among infants than in adults and children from other age
groups. In England and Wales, the overall yearly candidemia
incidence was found to be 1.52/100,000 population and it
was reported that among infants aged under 1 year old, the
rate was 11/100,000.19
Data from hospital-based studies
A review of surveillance studies reveals that, along with
population-based studies, there are many multicenter studies
involving hospitalized patients. Since such studies calculate
incidence rates based on the number of patients admitted to
hospitals or on hospitalization days, it may be more appropri-
ate to compare the results of those studies between each other.
As in community-based surveillance studies, regional differ-
ences also appear in studies investigating infection frequency
among hospitalized patients. According to the statistics of
the National Hospital Discharge Survey, yearly IC incidence
in the US between 1996 and 2003 was 19–24 infections per
10,000 hospital discharges.1
Two multicenter epidemiological studies covering the
years 2008–2009 and 2009–2010 were conducted in Spain.
Tertiary hospitals with high bed capacity were included into
both. According to the results of these studies, candidemia
incidence in 2008–2009 and 2009–2010 was 1.09 cases/1,000
admissions and 0.92 cases/1,000 admissions, respectively.20,21
In Italy, an increase in the candidemia rate was reported
between 1999 and 2009 according to the results of multicenter
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Candidiasis epidemiology
studies. The candidemia rate was found as 1.19 cases/1,000
admissions in 2009, while this rate was 0.38/1,000 admissions
in the 1997–1999 period.22
Although a smaller number of studies on IC have
been conducted in Latin America than in North America,
some multicenter studies provide information about IC
epidemiology. A study including seven countries and
conducted between 2008 and 2010 reported a candidemia
incidence of 1.18/1,000 admissions. In the study, the
country with the highest incidence rate was Argentina
(1.95 cases per 1,000 admissions), followed by ­Venezuela
(1.72 cases per 1,000 ­admissions), Brazil (1.38 cases per
1,000 admissions), Honduras (0.90 cases per 1,000 admis-
sions), Ecuador (0.90 cases per 1,000 admissions), and Chile
(0.33 cases per 1,000 admissions).23 The first multicenter
and laboratory-based surveillance study in Brazil, which
was conducted in 2003–2004, reported a high incidence
of candidemia (2.49 cases per 1,000 admissions).24 The
reason behind this higher candidemia incidence in Brazil is
not fully understood. However, this may result from some
problems affecting developing countries such as limited
resources, insufficient infection control methods due to
undereducated health care personnel, and less aggressive
empirical antifungal treatment and prophylaxis.24,25 In the
study performed by Nucci et al in the 2008–2010 period, the
incidence of IC in Brazil decreased to 1.38 cases per 1,000
admissions.23 The review of the literature did not reveal any
hospital-based studies on the incidence of IC in Asia-Pacific
countries and Africa.
Data from special patient groups
The review showed that, in studies about the epidemiology of
Candida infections, the frequency and characteristics of these
infections have been separately investigated for ICU patients
and specific patient groups such as those with underlying
hematological or solid organ malignancies. In ICUs, which
are hospital areas at high risk for Candida infections, the
incidence of candidemia increases in parallel with the increase
in general population. Data from the SENTRY Antimicrobial
Surveillance Program, which was an international surveillance
research program including several countries from Europe,
North America, and Latin America, showed that 44.5% of
candidemias were ICU-acquired in the 2008–2009 period.26
Various studies have shown that the rate of candidemia in
the ICU to be 0.5–32 cases per 1,000 admissions.27–32 In the
Extended Prevalence of Infection in Intensive Care (EPIC II)
study conducted in ICUs throughout the world in 2007, the
prevalence of Candida bloodstream infections was reported as
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Table 1 Incidence rates of invasive candidiasis

Country Study Rate/1,000 Rate/10,000 Rate/100,000 Reference
period admissions patient-days population
International studies
Europe ECMM 1997–1999 35
•  France 0.20
•  Germany
•  Italy 0.38 3.1
•  Sweden 0.32 4.4
•  UK 3.0
Latin America 2008–2010 1.18 2.3 23
•  Argentina 1.95 2.4
•  Brazil 1.38 2.6
•  Chile 0.33 0.9
•  Colombia 1.96 1.6
•  Ecuador 0.90 1.6
•  Honduras 0.90 2.5
•  Venezuela 1.72 –
Nationwide and multicenter studies
United States (CDC) 1992–1993 7.28 1
United States 2000 3.65 10
2005 5.56 10
United States 2008–2011 11,12
•  Atlanta 13.3
•  Baltimore 26.2
Canada 1992–1996 0.45 36
Finland 1995–1999 1.9 37
2004–2007 2.86 16
Sweden 2005–2006 4.2 17
Switzerland (FUNGINOS) 1991–2000 0.49 38
Denmark 2004–2009 8.6 14
2010–2011 9.4 15
Spain 2002–2003 0.53 0.73 4.3 39
2008–2009 1.09 20
2009–2010 0.92 21
Italy 2009 1.19 1.20 22
UK 1997–1999 1.87 0.3 40
Norway 1991–2003 2.4 41
Brazil 2003–2004 2.49 3.7 24
Australia 2001–2004 0.21 1.81 18
Japan 2008–2012 0.004–0.008 42
Thailand 2005–2007 1.2 43
Studies performed for specific patient populations
US (hematological malignancy) 2001–2007 1.9 44
EPIC II study* (ICU) 2007 6.87 33
France (ICU) 2001–2002 6.7 45
Italy (ICU) 1983–2002 2.6 3.3 27
Italy (ICU-AURORA) 2007–2008 16.5 46
People’s Republic of China (ICU) 2009–2011 32 32
Germany (ICU) 2006–2011 0.7 47
Turkey (ICU) 2004–2008 12.3 23.1 48
Germany (pediatric) 1998–2008 0.47 49
UK 2000–2009 19
•  ,15 years 1.52
•  ,1 year 11
Note: *Extended prevalence of infection in ICU.
Abbreviations: CDC, Centers for Disease Control and Prevention; ECMM, European Confederation of Medical Mycology; FUNGINOS, fungal infection network of
Switzerland; ICU, intensive care unit.

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Table 2 Species distribution of Candida species isolated in global studies (%)

Year Description Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1997–2007 Laboratory-based 53 65.3 7.2 6.0 11.3 2.4
ARTEMIS
•  1997–2000 70.9 5.4 4.8 10.2 2.2
•  2001–2004 62.9 7.5 6.9 11.5 2.5
•  2005–2007 65 8.0 5.6 11.7 2.5
2003 Laboratory-based 54 48.7 10.9 17.3 17.2 1.9
SENTRY
2008–2009 Laboratory-based 57 48.4 10.6 17.1 18.2 2.0
SENTRY
2007–2011 Hospital-based, pediatric 55 44 22 11 3

6.87 per 1,000 ICU patients.33 It has been determined that 36%
of invasive fungal infections are caused by yeast in patients
with hematological malignancies and Candida species are
the cause in 91% of these yeast infections.34 In patients with
hematological or solid organ malignancies and neutropenia,
C. glabrata and C. tropicalis are more commonly seen than
the other Candida species. On the other hand, C. krusei is the
most commonly encountered Candida species in patients who
have undergone hematopoietic stem cell transplantation and
in patients receiving fluconazole prophylaxis.2
The results of the studies about IC incidence that
could be accessed in the literature review are summarized
in Table 1.1,10–12,14–24,35–49
As seen from the results of the studies mentioned above,
IC exhibits different regional incidence rates throughout
the world and epidemiological features of IC may change
depending on geographic region. The reasons for those dif-
ferences are not completely known, but probably are related
to a combination of factors including differences in patient
demographics (such as age, sex, etc) and comorbidities.
Incidence of IC is higher among infants younger than 1 year
old and adults older than 70 years old.35,50 Patient groups that
have high risk for development of IC are patients hospitalized
in ICUs, patients with solid or hematological malignancy,
or patients undergoing surgery, especially major abdominal
or thoracic operations.2,9 Other reasons for the changing
incidence rates in different series and countries may also
be related to bed size of hospitals included in the studies;
differences in medical practices such as the use of long-
term vascular catheters, antibacterial and antifungal agents;
differences in resources available for diagnosis and medical
care; and insufficiency or difficulties in implementation of
infection control precautions.9,25,30
Species distribution
Although there are over 150 Candida species in nature,
only 15 of them are human pathogens. In the last 20 years,
a change has been observed in the rates of Candida species
isolated from patients with candidiasis. The incidence of
C. albicans has decreased, while that of the non-albicans
Candida has increased. Although this change has multiple
causes, the foremost of these are fluconazole use and the
increasing popularity of venous catheters.1,2,9,50–52 A review
of national, regional, and worldwide studies may show
that, throughout the years, the incidence of C. albicans has
declined from 70% to 50%.51 It has been reported that, in
North America and many European countries, the gradually
decreasing C. albicans infections have been replaced by

Table 3 Species distribution of Candida species isolated from North America (%)
Year Description Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1992–1996 Canada (three centers) 36 64 11 11 11 –
1997–2007 Laboratory-based 53 48.9 7.3 13.6 21.1 3.1
ARTEMIS (USA)
2004–2008 Hospital-based 56 42.1 8.7 15.9 26.7 3.4
PATH–ALLIANCE (USA)
2008–2009 Laboratory-based 57 43.4 10.5 17.1 23.5 1.9
SENTRY (USA)
2008–2011 Population-based (USA) 11,12 38 10 17 29 –

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Table 4 Species distribution of Candida species isolated from Latin America (%)
Year Description Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1997–2007 ARTEMIS Latin America 53 51.8 13.2 10.3 7.4 1.4
2008–2009 SENTRY Latin America 57 43.6 17.0 25.6 5.2 1.4
2007–2008 Argentina Laboratory-based 59 38.4 15.4 26.0 4.3 0.4
2008–2010 Laboratory-based 23
•  Argentina 42.5 16.8 23.9 6.2 1.8
•  Brazil 40.5 13.2 25.8 10.0 4.7
•  Chile 42.1 10.5 28.9 7.9 7.9
•  Colombia 36.7 17.4 38.5 4.6 –
•  Ecuador 52.2 10.9 30.4 4.3 –
•  Honduras* 27.4 26.7 14.1 3.7 3.0

C. glabrata infections, while the incidence of C. parapsilosis
or C. tropicalis infections has increased in other regions.
The distribution of Candida species causing IC is shown
in Table 2.53–55,57
In North America, the isolation ratio of C. albicans was
64% in Canada and 48.9% in USA in the 1990s.36,53 This
ratio was decreased to 38% in the 2008–2011 period and
there was a gradual increase in the ratio of C. tropicalis, C.
parapsilosis, and C. glabrata (Table 3).11,12,36,53,56,57
A close examination of the distribution of Candida
species causing IC in Latin America countries shows that
C. albicans is the most commonly encountered species.
However, unlike North America, C. glabrata infections are
not so common in Latin America. Instead, the second most
common infectious agent is C. parapsilosis in many Latin
America countries. It has been reported that C. parapsilosis,
an infectious agent that mostly affects neonates or patients
with venous catheters hospitalized in ICUs, is seen among
all age groups in Latin America.25 Although not clearly
identified, it is assumed that this result is associated with
insufficient catheter maintenance and infection control
methods. A multinational, laboratory-based study from the
same region showed that C. guilliermondii infections were
also common, especially in Honduras. This may be explained
by the outbreaks that occurred in the region when the study
was conducted (Table 4).23,53,58,59

Table 5 Species distribution of Candida species isolated from Europe (%)

Year Location Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1997–1999 ECMM Europe 35 56.4 7.2 13.3 13.6 1.9
1997–2007 ARTEMIS Europe 53 67.9 4.9 4.2 11.3 3.4
2008–2009 SENTRY Europe 57 55.2 7.3 13.7 15.7 2.5
2002 Belgium 58 55 2.8 13 22 2.3
2004–2009 Denmark 14 57.1 4.8 3.7 21.1 4.1
2010–2011 Denmark 15 52.1 4.1 4.2 28 4.8
1995–1999 Finland 37 70 3 5 9 8
2004–2007 Finland 16 67 2 5 19 3
2004–2005 Germany 60 58.5 7.5 8 19.1 1.4
2006–2011 Germany (ICU) 47 66
2007–2008 Italy (AURORA-ICU) 46 40.2 9.8 36.9 9.8 –
2009 Italy 22 50.4 8.2 14.8 20.3
1991–2003 Norway 41 69.8 6.7 5.8 13.2 1.6
2008–2009 Spain 20 49.0 10.7 20.7 13.6 2.1
2009–2010 Spain (FUNGEMYCA) 21 44.7 8.2 26.6 11.5 2.0
2009–2010 Spain FUNGEMYCA (pediatric) 61 36.5 5.9 46.8 3.9 1.0
2005–2006 Sweden 17 60.8 2.0 8.9 20.1 1.2
1991–2000 Switzerland (FUNGINOS) 38 68 9 1 15 2
1997–1999 UK and Wales 40 64.7 4.4 7.4 16.2 2.9
2008 UK 62 53.7 3.2 10.7 25.8 1.0
2008–2009 Turkey 63 45.8 24.1 14.5 4.8 –
Abbreviations: ECMM, European Confederation of Medical Mycology; FUNGINOS, fungal infection network of Switzerland; ICU, intensive care unit.

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Table 6 Species distribution of Candida species isolated from Asia-Pacific region (%)
Year Description Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1997–2007 ARTEMIS Asia-Pacific 53 64.4 11.7 7.4 12.6 1.2
2008–2009 SENTRY Asia-Pacific 57 56.9 11.7 13.7 13.7 2.0
2001–2004 Australia 18 47.3 5.1 19.9 15.4 4.3
2001–2004 Australia (ICU) 29 62 5.6 7.8 17.9 3.9
2000–2009 People’s Republic 64 35.9 21.8 7.7 12.9 –
of China (single center)
2009–2011 People’s Republic 32 41.8 17.6 23.8 12.3 –
of China (ICU)
2005–2007 Thailand 43 35.6 27.1 15.7 16.3 –
Abbreviation: ICU, intensive care unit.

In European countries, species distribution of Candida
isolates differs from one country to another. For example, in
Finland, the incidence of C. albicans as a percentage of total
Candida was found to be 70% and 67% in the 1995–1999 and
2004–2007 periods, respectively.16,37 C. glabrata is the second-
most common species. Similarly, in Sweden and ­Switzerland,
the ratio of C. albicans is above 60% and followed by
C. glabrata.17,38 However, in Spain the ratio of C. albicans
is below 50% and the most common non-albicans Candida
species is C. parapsilosis.20,21,61 Likewise, in another Mediter-
ranean country, Italy, C. albicans is responsible for almost
50% of the IC cases and followed by C. parapsilosis.22,46 In
Germany, Denmark, and the UK, C. albicans is isolated from
more than 50% of cases and the second-most common isolate
is C. glabrata (Table 5).14–17,20–22,35,37,38,40,46,47,53,57,59–63
Although a small number of multicenter and comprehen-
sive studies have been conducted in Asia-Pacific countries,
Australia, Africa, and the Middle East, those that could be
accessed point out a decrease in non-albicans Candida spe-
cies (Tables 6 and 7).18,29,32,43,53,57,64,65
Candida infections are commonly seen among cancer
patients, and of these infections, 49% are caused by C. albicans,
while 11%, 10%, 9%, and 11% are caused by C. tropicalis,
C. glabrata, C. krusei, and C. parapsilosis, respectively.66 The
same study also reported that, in patients with hematological
malignancies, C. albicans declined to 36%, while C. tropicalis
was seen among 14% of these patients and C. parapsilosis,
C. glabrata, and C. krusei share a rate of 13%.66
From the perspective of species distribution of isolates
causing IC, geographic variations are also seen as in the
incidence rate. The cause of these variations is multifactorial,
but the most important factors affecting species distribution
are differences in the antifungal treatment practices and
frequency of using invasive procedures such as indwelling
catheters.2 In addition, demographical features of patients and
chronic underlying diseases are also important for causative
agents. For example, while C. parapsilosis is isolated from
candidemia in young infants, C. glabrata is more common
among older patients.1,2
In the studies investigating risk factors for candidemia
caused by non-albicans Candida species, the duration of
central venous catheter use; prophylactic or therapeutic flu-
conazole use; and proportion of days of fluconazole exposure,
gastrointestinal surgery, older age, intravenous drug use, glu-
cocorticoid therapy, and candiduria were found as significant
risk factors, especially for C. glabrata and C. krusei. Younger
age, prior exposure to echinocandin antifungals, and insuf-
ficiency in infection control practices have been associated
with C. parapsilosis infections.29,30,67
Risk factors for IC
Risk factors for IC may be assigned into two groups: host-
related factors and health-care-associated factors including
catheter use, total parenteral nutrition, surgical interventions,
and the use of antimicrobial drugs. The leading host-related
factors are immunosuppressive diseases, neutropenia, age,
and a deteriorating clinical condition due to underlying
diseases.2,28,29,31 The most common health-care-associated
risks are long hospital or ICU stay.1 Risk factors associ-
ated with long ICU stay include invasive interventions and

Table 7 Species distribution of Candida species isolated from Africa and Middle-East region (%)
Year Description Reference Candida Candida Candida Candida Candida
albicans tropicalis parapsilosis glabrata krusei
1997–2007 ARTEMIS (Africa-Middle East) 53 67.1 6.6 6.0 8.8 1.6
1990–2007 South Africa (single center) 65 45.9 3.3 25 19.8 3.3

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colonization. Candida colonization is a risk factor, the impor-
tance of which has been realized in recent years. According
to various studies, this risk factor for IC development is more
related to the presence or absence of colonization than the
number of regions colonized.68,69 However, the detection of
colonization in any part of the body is only a risk factor, not
a disease, and treatment should not be started. Regardless,
the lack of Candida colonization is a strong indicator in favor
of excluding IC diagnosis.68,69
There are many studies in the literature that include
patients hospitalized in ICUs and aim at determining risk fac-
tors for candidemia. A study by Leroy et al, which included
180 ICUs in France, reported the following as risks factors
for candidemia due to IC: surgical interventions, mechanical
ventilation, previously received antibiotic treatment, neutro-
penia, and solid tumor and hematological malignancies.31
In another study investigating significant risk factors in
patients with candidemia, total length of hospital stay, the
presence of central venous catheters, previous candidemia
attacks, parenteral nutrition, and chronic renal insufficiency
were identified as significant risk factors through multivariate
logistic regression analyses.70
The increase in the number of IC cases caused by non-
­albicans Candida species has required a closer inspection
of risk factors. A study conducted between 2001 and 2005
in Greece identified glucocorticoid use, presence of central
venous catheters, and candiduria as independent risk factors
for infections due to non-albicans species.30 A similar study
Table 8 Risk factors for invasive candidiasis for adults and children
Hematological or solid malignancies
Neutropenia
Renal failure
Severe acute pancreatitis
Organ transplantation
Long hospitalization period in the intensive care unit
High APACHE II (Acute Physiology and Chronic Health Evaluation) score
Hemodialysis
Usage of antibiotics with broad spectrum
Usage of antifungal agents
Presence of central venous catheters
Mechanical ventilation
Total parenteral nutrition
Usage of immunosuppressive agents
Colonization with Candida species
Surgical procedures
For neonates and children, in addition to adults
Prematurity
Low birth weight
Low APGAR (American Pediatric Gross Assessment) score
Congenital malformations
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conducted in the USA between 1995 and 2005 reported that
the duration of fluconazole treatment and of central venous
catheterization are significant risk factors for the development
of candidemia.67 A national prospective study from Australia,
which was conducted during 2001–2005 and included 50 ICUs,
identified the following as significant risk factors for non-
albicans Candida infections: previous systematic antifungal
therapy, gastrointestinal surgery, old age, and intravenous drug
use.28 Risk factors for IC are summarized in Table 8.
Conclusion
Unfortunately, studies about the epidemiology of IC do not
present easily comparable figures. This results mostly from
the different characteristics of the study methods and study
groups. Studies conducted in a certain region are more benefi-
cial in determining the changes in infection frequency. While
national and population-based surveillance data collected
in the USA and European countries provide a more reliable
comparison, most of the studies conducted in other regions
are based on single hospitals. Although population-based
studies give an idea about the incidence of IC in the general
population, those conducted in hospitals base their rates on
the number of hospital admissions or hospital stay. Moreover,
it is very likely that IC incidence rates might have been
determined to be higher than normal in surveillance studies
based on hospitals, since the majority of patients included in
these studies have underlying chronic diseases and invasive
interventions are common procedures in hospitals. Thus, it is
difficult to properly interpret the results about the epidemiol-
ogy of IC in spite of the numerous studies on the subject.
Despite all of the complicated data, it can be assumed in
light of a rough evaluation of the epidemiologic studies that
the incidence of IC has increased throughout the world. This
increase is most pronounced among specific patient groups,
especially those hospitalized in ICUs. A similar increase is
also noted in population-based studies. Although there are
a small number of national and multinational studies on
infection frequency, it can be asserted that the incidence of
IC varies from one country to another. To illustrate, studies
from the USA report higher incidence rates compared to
those from the European countries. As for European coun-
tries, IC incidence is generally low except for Denmark,
where the rate is close to that of the USA.
In addition to the increase in infection frequency, another
intriguing development is the change in the distribution of the
pathogens causing IC. Until recently, C. albicans was respon-
sible for the majority of infections. However, hospital- and
community-acquired infections by non-albicans species have
Therapeutics and Clinical Risk Management 2014:10
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become more common today. In some parts of the world, this
increase is more pronounced in specific patient groups such
as hematologic malignancy patients. Global studies report a
decrease from 65% to 44% in cases of IC caused by C. ­albicans
between the late 1990s and 2010. However, an increase in
the incidence of C. tropicalis and C. parapsilosis has been
observed (Table 2). The greatest clinical risk posed by non-
albicans Candida species, which have become more common,
is the changes in their sensitivity to frequently used antifungal
agents. Thus, the incidence of these species is closely moni-
tored throughout the world. Similarly to infection frequency,
the results of studies related to this subject vary between
geographical regions. For instance, C. glabrata incidence is
high in the USA, whereas the most commonly observed spe-
cies in studies from Latin America and Asia-Pacific countries
are C. tropicalis and C. parapsilosis (Tables 3 and 4). As for
Europe, as a whole, C. glabrata and C. parapsilosis are among
the most common pathogens. The incidence of C. parapsilosis
is also significantly high in Mediterranean countries.
Despite all epidemiological data, IC still has high
crude and attributable mortality. For better management of
Candida infections, it is crucial to obtain sufficient epide-
miological data. To this end, both infection frequency and
species distribution must be regularly monitored through
well-planned studies.
Disclosure
The author reports no conflicts of interest in this work.
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